Bottom Line:
Mixed models analyses using the full intention-to-treat sample revealed significant interaction effects of group and time on all outcome measures, when comparing treatment to the control group.A large between-group effect size of Cohen's d = 0.77 (95% CI: 0.37-1.18) was found on the PHQ-9 and a moderately large between-group effect size d = 0.48 (95% CI: 0.08-0.87) was found on the GAD-7.The results support the conclusion that psychodynamic treatment approaches may be transferred to the guided self-help format and delivered via the Internet.

ABSTRACTBackground. Psychodynamic psychotherapy is a psychological treatment approach that has a growing empirical base. Research has indicated an association between therapist-facilitated affective experience and outcome in psychodynamic therapy. Affect-phobia therapy (APT), as outlined by McCullough et al., is a psychodynamic treatment that emphasizes a strong focus on expression and experience of affect. This model has neither been evaluated for depression nor anxiety disorders in a randomized controlled trial. While Internet-delivered psychodynamic treatments for depression and generalized anxiety disorder exist, they have not been based on APT. The aim of this randomized controlled trial was to investigate the efficacy of an Internet-based, psychodynamic, guided self-help treatment based on APT for depression and anxiety disorders. Methods. One hundred participants with diagnoses of mood and anxiety disorders participated in a randomized (1:1 ratio) controlled trial of an active group versus a control condition. The treatment group received a 10-week, psychodynamic, guided self-help treatment based on APT that was delivered through the Internet. The treatment consisted of eight text-based treatment modules and included therapist contact (9.5 min per client and week, on average) in a secure online environment. Participants in the control group also received online therapist support and clinical monitoring of symptoms, but received no treatment modules. Outcome measures were the 9-item Patient Health Questionnaire Depression Scale (PHQ-9) and the 7-item Generalized Anxiety Disorder Scale (GAD-7). Process measures were also included. All measures were administered weekly during the treatment period and at a 7-month follow-up. Results. Mixed models analyses using the full intention-to-treat sample revealed significant interaction effects of group and time on all outcome measures, when comparing treatment to the control group. A large between-group effect size of Cohen's d = 0.77 (95% CI: 0.37-1.18) was found on the PHQ-9 and a moderately large between-group effect size d = 0.48 (95% CI: 0.08-0.87) was found on the GAD-7. The number of patients who recovered (had no diagnoses of depression and anxiety, and had less than 10 on both the PHQ-9 and the GAD-7) were at post-treatment 52% in the treatment group and 24% in the control group. This difference was significant, χ(2)(N = 100, d f = 1) = 8.3, p < .01. From post-treatment to follow-up, treatment gains were maintained on the PHQ-9, and significant improvements were seen on the GAD-7. Conclusion. This study provides initial support for the efficacy of Internet-delivered psychodynamic therapy based on the affect-phobia model in the treatment of depression and anxiety disorders. The results support the conclusion that psychodynamic treatment approaches may be transferred to the guided self-help format and delivered via the Internet.

fig-2: Malan’s two triangles - the triangle of conflict and the triangle of person.The two triangles (Malan, 1995) represent what David Malan called “the universal principle of psychodynamic psychotherapy”. That is, defenses (D) and anxieties (A) can block the expression of true feelings (F). These patterns began with past persons (P), are maintained with current persons (C), and are often enacted with the therapist (T).

Mentions:
One psychodynamic treatment that has a strong focus on expression and experience of affect is affect-phobia therapy (APT), developed by McCullough et al. (2003). APT follows a treatment model which adheres to the fundamental structure of psychodynamic psychotherapy as outlined by Malan’s triangle of conflict (i.e., the experience/expression of feelings (F) is blocked by defenses (D) and anxieties (A)) and triangle of person (i.e., conflicted patterns began with past persons (P), are maintained with current persons (C), and can be enacted with a therapist (T)), as illustrated in Fig. 2 (Malan, 1995). Typically in APT, the therapist clarifies a client’s defenses, helps the client to observe and experience the underlying affects, and helps the client to regulate associated anxiety (McCullough et al., 2003). Formally, the treatment includes three main treatment objectives: defense restructuring (recognizing and relinquishing maladaptive defenses), affect restructuring (desensitization of affects through exposure to conflicted feeling), and self/other restructuring (improvement in sense of self and relationship with others). The main goal of psychodynamic psychotherapy based on the APT model is to help clients experience and to adaptively express previously avoided feelings (McCullough et al., 2003). That goal is shared with an entire set of psychodynamic psychotherapies that are grouped under the umbrella term experiential dynamic therapies (Osimo & Stein, 2012), which in addition to APT includes, for example, Intensive Short-Term Dynamic Psychotherapy (Abbass, Town & Driessen, 2012; Davanloo, 2000), and Accelerated Experiential Dynamic Psychotherapy (Fosha, 2000). Two randomized trials, investigating the efficacy of APT in the treatment of personality disorders, found that APT can be effective in reducing general psychiatric symptoms (Svartberg, Stiles & Seltzer, 2004; Winston et al., 1994). However, except for case-series and some small uncontrolled studies (e.g., Dornelas et al., 2010), to date no trial has investigated the efficacy of APT for patients with a principal Axis I disorder.

fig-2: Malan’s two triangles - the triangle of conflict and the triangle of person.The two triangles (Malan, 1995) represent what David Malan called “the universal principle of psychodynamic psychotherapy”. That is, defenses (D) and anxieties (A) can block the expression of true feelings (F). These patterns began with past persons (P), are maintained with current persons (C), and are often enacted with the therapist (T).

Mentions:
One psychodynamic treatment that has a strong focus on expression and experience of affect is affect-phobia therapy (APT), developed by McCullough et al. (2003). APT follows a treatment model which adheres to the fundamental structure of psychodynamic psychotherapy as outlined by Malan’s triangle of conflict (i.e., the experience/expression of feelings (F) is blocked by defenses (D) and anxieties (A)) and triangle of person (i.e., conflicted patterns began with past persons (P), are maintained with current persons (C), and can be enacted with a therapist (T)), as illustrated in Fig. 2 (Malan, 1995). Typically in APT, the therapist clarifies a client’s defenses, helps the client to observe and experience the underlying affects, and helps the client to regulate associated anxiety (McCullough et al., 2003). Formally, the treatment includes three main treatment objectives: defense restructuring (recognizing and relinquishing maladaptive defenses), affect restructuring (desensitization of affects through exposure to conflicted feeling), and self/other restructuring (improvement in sense of self and relationship with others). The main goal of psychodynamic psychotherapy based on the APT model is to help clients experience and to adaptively express previously avoided feelings (McCullough et al., 2003). That goal is shared with an entire set of psychodynamic psychotherapies that are grouped under the umbrella term experiential dynamic therapies (Osimo & Stein, 2012), which in addition to APT includes, for example, Intensive Short-Term Dynamic Psychotherapy (Abbass, Town & Driessen, 2012; Davanloo, 2000), and Accelerated Experiential Dynamic Psychotherapy (Fosha, 2000). Two randomized trials, investigating the efficacy of APT in the treatment of personality disorders, found that APT can be effective in reducing general psychiatric symptoms (Svartberg, Stiles & Seltzer, 2004; Winston et al., 1994). However, except for case-series and some small uncontrolled studies (e.g., Dornelas et al., 2010), to date no trial has investigated the efficacy of APT for patients with a principal Axis I disorder.

Bottom Line:
Mixed models analyses using the full intention-to-treat sample revealed significant interaction effects of group and time on all outcome measures, when comparing treatment to the control group.A large between-group effect size of Cohen's d = 0.77 (95% CI: 0.37-1.18) was found on the PHQ-9 and a moderately large between-group effect size d = 0.48 (95% CI: 0.08-0.87) was found on the GAD-7.The results support the conclusion that psychodynamic treatment approaches may be transferred to the guided self-help format and delivered via the Internet.

ABSTRACTBackground. Psychodynamic psychotherapy is a psychological treatment approach that has a growing empirical base. Research has indicated an association between therapist-facilitated affective experience and outcome in psychodynamic therapy. Affect-phobia therapy (APT), as outlined by McCullough et al., is a psychodynamic treatment that emphasizes a strong focus on expression and experience of affect. This model has neither been evaluated for depression nor anxiety disorders in a randomized controlled trial. While Internet-delivered psychodynamic treatments for depression and generalized anxiety disorder exist, they have not been based on APT. The aim of this randomized controlled trial was to investigate the efficacy of an Internet-based, psychodynamic, guided self-help treatment based on APT for depression and anxiety disorders. Methods. One hundred participants with diagnoses of mood and anxiety disorders participated in a randomized (1:1 ratio) controlled trial of an active group versus a control condition. The treatment group received a 10-week, psychodynamic, guided self-help treatment based on APT that was delivered through the Internet. The treatment consisted of eight text-based treatment modules and included therapist contact (9.5 min per client and week, on average) in a secure online environment. Participants in the control group also received online therapist support and clinical monitoring of symptoms, but received no treatment modules. Outcome measures were the 9-item Patient Health Questionnaire Depression Scale (PHQ-9) and the 7-item Generalized Anxiety Disorder Scale (GAD-7). Process measures were also included. All measures were administered weekly during the treatment period and at a 7-month follow-up. Results. Mixed models analyses using the full intention-to-treat sample revealed significant interaction effects of group and time on all outcome measures, when comparing treatment to the control group. A large between-group effect size of Cohen's d = 0.77 (95% CI: 0.37-1.18) was found on the PHQ-9 and a moderately large between-group effect size d = 0.48 (95% CI: 0.08-0.87) was found on the GAD-7. The number of patients who recovered (had no diagnoses of depression and anxiety, and had less than 10 on both the PHQ-9 and the GAD-7) were at post-treatment 52% in the treatment group and 24% in the control group. This difference was significant, χ(2)(N = 100, d f = 1) = 8.3, p < .01. From post-treatment to follow-up, treatment gains were maintained on the PHQ-9, and significant improvements were seen on the GAD-7. Conclusion. This study provides initial support for the efficacy of Internet-delivered psychodynamic therapy based on the affect-phobia model in the treatment of depression and anxiety disorders. The results support the conclusion that psychodynamic treatment approaches may be transferred to the guided self-help format and delivered via the Internet.